By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (Alectinib) Covered by Aetna CVS Health in Washington: Complete PA Guide & Appeal Scripts

Answer Box: Getting Alecensa Covered by Aetna CVS Health in Washington

Alecensa (alectinib) is covered by Aetna CVS Health as a Tier 4 specialty medication with mandatory prior authorization. To get approved in Washington:

  1. Confirm ALK-positive status with FDA-approved testing results
  2. Submit CVS Specialty enrollment form with complete clinical documentation
  3. File prior authorization showing medical necessity and any required step therapy compliance

First step today: Have your oncologist gather your ALK test results, pathology report, and staging documentation. If denied, Washington residents have strong appeal rights through independent external review within 60 days.

Table of Contents

Plan Types & Coverage Implications

Aetna CVS Health offers multiple plan types in Washington, each with different coverage structures for specialty medications like Alecensa:

Commercial Plans (Employer-Sponsored)

  • HMO, PPO, and EPO options available
  • Specialty medications typically require CVS Specialty Pharmacy
  • Prior authorization mandatory across all plan types

Individual/Family Plans (ACA Marketplace)

  • Available through Washington Healthplanfinder
  • Tier 4 specialty placement with higher cost-sharing
  • Same PA requirements as commercial plans

Medicare Advantage

  • Different formulary structure with potential coverage gaps
  • 180-day appeal rights under federal regulations

Medicaid (Apple Health)

  • Managed through Aetna Better Health in some regions
  • State-specific coverage criteria may apply
Note: Self-funded employer plans may have different appeals timelines (45 days vs. 20 days for fully-insured plans in Washington).

Formulary Status & Tier Placement

Coverage at a Glance

Requirement Details Source
Formulary Status Covered, Tier 4 Specialty 2024 Aetna Exchange Formulary
Prior Authorization Required for all indications Aetna Specialty Drug List
Quantity Limits 240 capsules per 30 days Aetna Formulary Documents
Specialty Pharmacy CVS Specialty required CVS Specialty Enrollment
Step Therapy May require crizotinib trial first Aetna PA Criteria

Alternative ALK Inhibitors on Formulary:

  • Crizotinib (Xalkori) - typically first-line requirement
  • Brigatinib (Alunbrig) - similar tier placement
  • Lorlatinib (Lorbrena) - for resistance mutations

Prior Authorization Requirements

Medical Necessity Criteria

Aetna requires comprehensive documentation for Alecensa approval:

Essential Clinical Documentation:

  • ALK-positive test results from FDA-approved assay (FISH, IHC, or RT-PCR)
  • Complete pathology report with staging (TNM classification)
  • ICD-10 diagnosis codes (typically C78.00-C78.09 for metastatic NSCLC)
  • Treatment history including prior therapies and outcomes

Step Therapy Considerations:

  • First-line use may require crizotinib contraindication or failure documentation
  • CNS metastases can justify bypassing step therapy requirements
  • Prior intolerance must be clearly documented with specific adverse events

Clinician Corner: Medical Necessity Letter Checklist

Your oncologist's letter should include:

✓ Patient presentation: Age, performance status, smoking history ✓ Diagnosis confirmation: Histologic type, stage, ALK fusion details ✓ Prior treatments: Chemotherapy, radiation, previous targeted agents ✓ Clinical rationale: Why Alecensa is preferred over alternatives ✓ Guideline support: Reference to NCCN guidelines or FDA labeling ✓ Monitoring plan: LFT and CPK monitoring schedule

CVS Specialty Pharmacy Setup

Enrollment Process

Required Forms:

Submission Methods:

  • Fax: (verify current number with CVS Specialty)
  • Online portal for registered providers
  • Phone enrollment: 1-800-237-2767

Processing Timeline:

  • Enrollment verification: 7-10 business days
  • Prior authorization: Additional 30-45 days
  • First shipment: 3-5 days after approval
Tip: Submit enrollment and PA simultaneously to avoid delays. CVS Specialty will coordinate both processes.

Step-by-Step: Fastest Path to Approval

1. Gather Essential Documentation

Who: Patient and care team Timeline: 1-2 days

  • ALK test results from certified lab
  • Complete pathology report
  • Insurance cards (front and back)
  • Prior therapy records if applicable

2. Complete CVS Specialty Enrollment

Who: Prescribing oncologist Timeline: Same day

  • Download and complete enrollment form
  • Include all required clinical documentation
  • Submit via fax or online portal

3. Submit Prior Authorization

Who: Oncologist's office Timeline: Same day as enrollment

  • Use Aetna provider portal or standard PA form
  • Attach medical necessity letter
  • Include ALK test results and staging information

4. Track Application Status

Who: Patient or care coordinator Timeline: Weekly follow-up

  • Call CVS Specialty: 1-800-237-2767
  • Check Aetna provider portal for PA status
  • Document all communications

5. Prepare for Potential Denial

Who: Care team Timeline: Within 30-45 days

  • Review denial letter for specific reasons
  • Gather additional documentation if needed
  • Prepare appeal strategy

6. File Appeal if Necessary

Who: Patient with oncologist support Timeline: Within 60 days of denial

  • Submit internal appeal to Aetna
  • Include peer-reviewed literature supporting use
  • Request expedited review if clinically urgent

7. External Review Option

Who: Patient Timeline: Within 60 days of final internal denial

  • File with Washington Office of Insurance Commissioner
  • Independent medical review by specialty expert
  • Binding decision on Aetna

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing ALK test Submit FDA-approved test results FISH, IHC, or RT-PCR report
Step therapy not met Document crizotinib failure/intolerance Treatment records, adverse event notes
Insufficient clinical information Provide comprehensive history Pathology, staging, treatment timeline
Non-formulary status Request formulary exception Medical necessity letter, guidelines
Experimental/investigational Cite FDA approval and guidelines FDA labeling, NCCN recommendations

Washington Appeals Process

Washington residents have robust protection against insurance denials through state-mandated external review.

Internal Appeals Timeline

  • First level: 30 days for standard review
  • Expedited: 72 hours for urgent cases
  • Required: Must complete before external review

External Review Process

  • Deadline: 60 days from final internal denial
  • Cost: Free to patient
  • Timeline: 20 days (fully-insured) or 45 days (self-insured)
  • Expedited: 72 hours for urgent cases
  • Decision: Binding on Aetna

How to Request External Review:

  1. Contact Aetna member services
  2. Submit written request with medical records
  3. Washington assigns certified Independent Review Organization (IRO)
  4. Board-certified oncologist reviews case
  5. Written decision issued within timeline
Important: Keep detailed records of all communications and deadlines. The Washington Office of Insurance Commissioner at 1-800-562-6900 can provide guidance throughout the process.

Cost-Share Dynamics

Typical Cost Structure

  • Tier 4 Specialty: 25-40% coinsurance after deductible
  • Monthly cost: $4,000-8,000+ depending on plan
  • Annual out-of-pocket maximum: Varies by plan type

Financial Assistance Options

  • Genentech Copay Program: May reduce out-of-pocket costs (verify eligibility)
  • Patient Access Network Foundation: Grants for ALK+ NSCLC patients
  • Washington State programs: Apple Health for eligible residents

Note: This information is educational only. Consult your plan documents for specific cost-sharing details.

Scripts & Templates

Patient Phone Script for Aetna

"Hi, I'm calling about prior authorization for Alecensa, prescription number [X]. My member ID is [Y]. Can you tell me the current status and what additional information might be needed? I'd also like to understand the timeline for a decision and my appeal rights if denied."

Clinic Staff Peer-to-Peer Request

"I'm requesting a peer-to-peer review for [patient name], member ID [X], regarding Alecensa prior authorization. The patient has ALK-positive metastatic NSCLC with [specific clinical details]. Dr. [oncologist name] is available for clinical discussion at [times]."

FAQ

How long does Aetna CVS Health prior authorization take in Washington? Standard PA decisions typically take 30-45 days. Expedited reviews for urgent cases can be completed within 72 hours.

What if Alecensa is denied for step therapy? Document crizotinib failure, intolerance, or contraindication. CNS metastases often justify bypassing step therapy requirements.

Can I request an expedited appeal in Washington? Yes, if your oncologist certifies that delay could seriously jeopardize your health. Expedited external reviews are decided within 72 hours.

Does Washington's external review apply to self-funded employer plans? Self-funded plans follow federal ERISA rules with 45-day external review timelines, but many voluntarily use Washington's process.

What happens if CVS Specialty is out-of-network? For specialty medications like Alecensa, Aetna typically requires CVS Specialty regardless of network status, often with in-network cost-sharing.

How do I verify my specific plan's coverage? Check your plan's formulary document or call member services. Each Aetna product may have slightly different requirements.

At Counterforce Health, we help patients and clinicians navigate complex insurance denials by turning them into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements. When facing an Alecensa denial from Aetna CVS Health, having the right evidence and procedural approach can make the difference between approval and continued delays in accessing this critical cancer treatment.

From our advocates: "We've seen Alecensa denials overturned most successfully when the appeal includes not just the ALK test results, but also a clear timeline of prior treatments and their outcomes. One case involved a patient whose initial denial cited 'insufficient clinical information,' but the appeal succeeded after we helped organize the medical records chronologically and highlighted the specific contraindications to crizotinib that made Alecensa the appropriate first-line choice."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult your healthcare provider and insurance plan documents for personalized guidance. For assistance with insurance appeals and coverage decisions, visit Counterforce Health.

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